CSUF University Extended Education Registration Form
This form is intended to be printed out. Please complete and return with fee payment

Sea Grant Online: Classroom Exploration of the Oceans

FAX:           (714) 278-2088
Telephone: (714) 278-2611
Mail:            CSUF Univ. Extended Education,   Rm. T-1415,   P.O. Box 6870, 
                     Fullerton, CA  92834-6870
Online:         www.csufextension.org

E-mail Address:_____________________________________________________

Date:_______________   Social Security #:_____________________

Name: (first, middle, last):__________________________________________________

Address (street number):___________________________________________________

City: ______________________________         State: _______          ZIP:___________

Day phone: _______________________   Evening phone: ________________________

Birthdate: _________________________       (please circle):      Female   or   Male

Schedule # Unit        Class Title                                            Date                  Fee

18768  1 Classroom Exploration/Ocean   4/21-12/19/03   $35

19300  2 Classroom Exploration/Ocean   4/21-12/19/03   $70

19301  3 Classroom Exploration/Ocean   4/21-12/19/03   $105

Instructor:  Francesca Cava

Workshop Participation Dates (weeks attended): ________________________________________

       _______________________________________________________________________________

     ________________________________________________________________________________

Payment by check, money order or credit card.  By CHECK or MONEY ORDER: make payable to CSUF.

To CHARGE (please circle):       VISA         MASTERCARD          AMERICAN EXPRESS      DISCOVER

Credit card # ____________________________________  Expiration date: _______________________

Cardholder Name: _________________________________________

Authorizing Signature:______________________________________

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